Diabetes and Pregnancy

Ideally prior to pregnancy you should make contact with a member of your diabetes team. At this review you need to optimising your insulin treatment prior to pregnancy, to start Folic Acid 5 mg once daily. Your diabetic complications specific reference to your eyes and your kidney disease should be assessed.
If you are on any medications for kidney disease or cholesterol lowering medications, these should be stopped and substituted with other treatment. Hypoglycaemia is more likely in pregnancy, and this needs to be anticipated.
Blood Glucose Control
Blood glucose targets you need to achieve during pregnancy are
tighter than during normal diabetic management. The aim should be to have a fasting blood glucose, fasting/pre-meal blood glucose of less than 5.8 mmol (but higher than 3.5 mmol) and a 2-hour post-meal blood glucose of less than 8 mmol. You may not be used to measuring your blood glucose after meals, but you will need to do this particularly after breakfast and 2 hours after your main meal. Monitoring blood glucose on 4-5 times on 2-3 days per week.
In addition to the daytime blood glucose monitoring, it is useful that you could check your blood glucose 4 hours after your night-time insulin dose. This value should be greater than 3.5 but less than 8.
Your insulin dose will change dramatically during pregnancy.
If you are on 2 injections of insulin per day, it is likely that you will have to be swapped onto 3-4 insulin injections per day. If you are taking either NovoRapid or Humalog insulin you will be able to continue this, and it may be necessary to swap you if you are another type of insulin onto one of the more rapidly acting insulin during pregnancy. The dose of insulin will change throughout pregnancy. In the first 2 months of pregnancy, particularly if you are having morning sickness, the dose of insulin may fall. If from about 16 weeks of pregnancy until 36 weeks of pregnancy, the insulin dose will increase. It may be 2 or 3 times higher than your non-pregnant insulin dose. You should anticipate these changes and expect to increase your dose of insulin. The increase in dose of insulin may be by bigger amounts than you normally take. So if you normally change your insulin by 2 units a day, you may need to increase it by 4 units.
Morning Sickness
Morning sickness is a nuisance for people on insulin treatment and may continue throughout the day. You need to continue your long acting insulin as normal and if you are suffering from morning sickness then take half of your normal insulin dose, try and eat something and then give the residual part afterwards. If you are unable to keep anything at all, then we will need to admit you and give you your insulin as an infusion in the hospital.
Hypoglycaemia
Hypoglycaemia is a major problem in pregnancy. There are two reasons for this. You will be running your blood glucose much more tightly than normal and this leaves you less room to make mistakes with your insulin treatment or diet. The second is that for reasons that we do not understand, the warning of low blood glucose diminishes during pregnancy. You need to prepare your partner on how to deal with hypoglycaemic episodes at night time. We will show your partner how to give Glucagon injections if your blood sugar is low and you cannot help yourself. In the daytime you should carry Lucozade or Dextrosol tablets and take ¾, 200 ml of a cup or 3 tablets immediately if you think your blood sugar is low. If however your blood glucose remains low, then this should be repeated after 10 minutes. You should also keep some Lucozade by your bed at night time, so that if you wake up feeling that your blood glucose is low, you will not have to get up to sort out your blood glucose.
What Happens to Diabetic Complications?
Eye Problems
Eye problems (retinopathy) can deteriorate during pregnancy. Your eyes should be checked prior to pregnancy or during early pregnancy and then again at 24 and 36 weeks in pregnancy. If there is any change in your retina, you will be referred to the ophthalmology department for further management.
Diabetic Kidney Disease
If you have had microalbuminuria, proteinuria or kidney disease diagnosed prior to pregnancy, these will need to be managed throughout pregnancy as they can change. The good news is however is there appears to be no long-term deterioration in kidney disease as a result of pregnancy. If you are on any of the Ace inhibitor drugs (Captopril, Enalapril etc.) you will need to be swapped onto Methyldopa. Ace inhibitors are not known to be safe during pregnancy. If you are known to have protein in your urine, then we will measure this throughout your pregnancy.
What Happens at Birth?
It is plan should be that you would have a normal delivery of your child, unless there are problems with your health or the baby’s health. There will be frequent assessments of your baby’s and your health in the last few weeks of pregnancy to make sure that this is safe thing to do. If there are problems with either your diabetic control, your general health or the baby’s health, it is likely that you will have an induction at sometime between 36 and 38 weeks of pregnancy and this will be discussed fully with you at the time.
Insulin Treatment at Delivery
When you think you have gone into labour or you are booked in to have an induction, you will need to stop all your insulin treatment. Let the Midwife and staff on the ward know that you are an insulin and diabetic patient and they will run an insulin and infusion drip along with glucose into your veins continuously until delivery of your baby. This would keep your blood glucose tightly controlled when you are not eating between 4-6 mmol.
When you go back onto your insulin treatment, it is sensible to reducethe dose by approximately 20% less than your pre-pregnancy dose of insulin. Breast milk is made of glucose, and is a drain of glucose from your body, which can make your blood glucose low at night. This tendency increases throughout the early part of breastfeeding as the milk production increases.

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